Prognosis. — The prognosis, even as regards life, is far from cheering. The aged and feeble patient is liable to pass into a cachectic or demented state and thus to fade away, often with hypostatic pneumonia.
Or he may die in a few days by the shock. After he has passed the third week, however, the prognosis is good.
As to union, it may be fibrous or fail entirely, such a result entailing in some cases no disability to speak of beyond the inconvenience of a shortened limb, while in others locomotion may be entirely lost.
Treatment. — The first indication is Energetic manipulations either for the purpose of eliciting crepitus or cor recting deformity have a tendency to tear the periostcum still farther and to sepa rate impacted fragments. Such shorten ing or eversion as cannot be overcome by the traction splint is best left uncor to save the patient's life, and to this all else must be subordinate. Such splints should be applied as will most promote the patient's comfort, and the disturb ance of repeated measurement and re dressing avoided. Careful nursing, feed rected, lest non-union be courted. Trac tion should be continued for at least five weeks and the patient kept in bed a week longer. The best traction-splints are Buck's and Hodgen's. Buck's is the more convenient for the surgeon, permit ing, and stimulating are of capital im portance. Premonitory signs of demen tia must be watched for, and if the pa tient seems to be failing he must be gotten out of bed, whether his thigh has united or not. In this event the hip ting accurate examination and measure ment without disturbing the dressing; but Hodgen's is more convenient for the patient, and should be preferred for the aged.
In Buck's extension the traction is should be disturbed as little as possible and the patient allowed to recline in a wheel-chair. Pressure over the trochan ter will encourage union, the pressure to be made by a pad under a pelvic band worn as tight as is compatible with the patient's comfort.
made by weight and pulley over the foot of the bed, which may be raised for coun ter-extension. It is applied as follows: A strip of stout adhesive plaster (the so called "moleskin-diachylon" plaster, al though it is rather difficult to apply, re quiring to be heated before it will adhere, —and if overheated it will blister the skin,—is least irritating), four inches wide and long enough to reach from well above the knee loosely around the sole of the foot and back above the knee again, is cut as shown in Fig. 9, and a small
perforated block of wood placed at its centre. Through the hole in the wood and a corresponding one in the plaster a cord is passed, so knotted at the end that it cannot slip through. The edges of the plaster are now turned down over the vented by employing Volkmann's sliding rest (Fig. 12), and sand-bags along the outer side of the thigh.
Hodgen's splint (Fig. 13) consists of two iron rods slightly bent at the connec tion of their upper and middle thirds and attached together by a straight bar at the lower ends and a curved one at the upper. The limb being attired as for Buck's extension (Fig. 11) the cord is attached to the straight cross-bar and a number of narrow compresses or pieces block and each other (Fig. 10). A roller bandage (preferably of flannel) is applied to the foot and lower third of the leg, the adhesive plaster applied to the sides of the leg and thigh above it, and the band age continued up over the plaster (Fig. 11). The cord is then carried over the pulley at the foot of the bed and attached to a weight of from 5 to 20 pounds, the heavier weights only being applied to robust and young patients whose short ening is not done away with by the lighter ones. Outward rotation is pre of bandage are pinned to one rod, passed under the limb, and pinned to the other in such a way as to give uniform support to the limb when it is raised from the bed. The apparatus is supported by two loops tied to a cord which is attached to a crane at a point at least four feet above the bed and at an angle of about ten degrees from the vertical.
Traction hip-splints, such as are used in hip-joint disease, have also been ap plied here. Their use is certainly a great convenience and will doubtless be more frequent in future. Unfortunately, how ever, they cannot be used by the very ones who need them most—the aged and infirm.
When the shortening has once been reduced some surgeons prefer to apply a plaster splint from waist to ankle at once. With such a splint pressure may be made over the trochanter through a fenestra to encourage union.
Excision of the head for non-union has been done with varying success, but fracture of the neck, to which are added independent mobility of the trochanter and a prominent tender spot in front of it.
Treatment.—Hodgen's splint.